Ahni Health Services Inc.

The agency failed to ensure utilization of OASIS data to improve program effectiveness, quality of patient care and overall program improvement for all 30 current patients and all employees.

The agency failed to ensure the initiation and review of a performance improvement project through their QAPI Program for 30 patients and all employees.

The agency failed to ensure an individualized plan of care for two (Patients #5 and 6) of 7 patients.

The agency failed to notify the physician of a change in wound status for one (Patient #4) of seven patients.

The agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 39 patients and all employees.

The agency failed to ensure a medication profile was reviewed and updated with an end date for an ordered medication for one (Patient #7) of 7 patients.

The agency failed to ensure an individualized patient POC included interventions and goals related to the primary diagnosis for one (Patient #3) of seven patients.

The agency failed to ensure SN visits were conducted per POC ordered frequency for two (Patient #5 and #6) of seven patients.

The agency failed to ensure a completed discharge summary was provided for two (Pt's #1 and #2) of two patients.

The agency failed to develop a patient centered QAPI Program.

The agency failed to: 1. ensure a physician order was obtained for physical therapy for one (Patient #3) of seven patients and 2. ensure physical therapy was provided as ordered for one (Patient #6) of seven patients.

The agency failed to develop a patient centered QAPI Program.

The agency failed to ensure the utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement.

The agency failed to develop PIPS to track adverse patient events.

The agency failed to develop performance improvement projects.

The agency failed to ensure an ongoing, comprehensive QAPI Program was developed, maintained and approved by the governing body.

The agency failed to develop performance improvement activities which focused on high risk or problem areas.

The agency failed to develop a QAPI program to identify potential threats to the health and safety of patients.

The agency failed to document performance improvement within the QAPI Program.